Infection In Immunocompetent Patients Research Articles

Cytokine/Chemokine Expression Is Closely Associated Disease Severity of Human Adenovirus Infections in Immunocompetent Adults and Predicts Disease Progression.

Increasing human Adenovirus (HAdV) infections complicated with acute respiratory distress syndrome (ARDS) even fatal outcome were reported in immunocompetent adolescent and adult patients. Here, we characterized the cytokine/chemokine expression profiles of immunocompetent patients complicated with ARDS during HAdV infection and identified biomarkers for disease severity/progression. Forty-eight cytokines/chemokines in the plasma samples from 19 HAdV-infected immunocompetent adolescent and adult patients (ten complicated with ARDS) were measured and analyzed in combination with clinical indices. Immunocompetent patients with ARDS caused by severe acute respiratory disease coronavirus (SARS-CoV)-2, 2009 pandemic H1N1 (panH1N1) or bacteria were included for comparative analyses. Similar indices of disease course/progression were found in immunocompetent patients with ARDS caused by HAdV, SARS-CoV-2 or panH1N infections, whereas the HAdV-infected group showed a higher prevalence of viremia, as well as increased levels of aspartate aminotransferase (AST), alanine aminotransferase (ALT) and creatine kinase (CK). Expression levels of 33 cytokines/chemokines were increased significantly in HAdV-infected patients with ARDS compared with that in healthy controls, and many of them were also significantly higher than those in SARS-CoV-2-infected and panH1N1-infected patients. Expression of interferon (IFN)-γ, interleukin (IL)-1β, hepatocyte growth factor (HGF), monokine induced by IFN-γ (MIG), IL-6, macrophage-colony stimulating factor (M-CSF), IL-10, IL-1α and IL-2Ra was significantly higher in HAdV-infected patients with ARDS than that in those without ARDS, and negatively associated with the ratio of the partial pressure of oxygen in arterial blood/fraction of inspired oxygen (PaO2/FiO2). Analyses of the receiver operating characteristic curve (ROC) showed that expression of IL-10, M-CSF, MIG, HGF, IL-1β, IFN-γ and IL-2Ra could predict the progression of HAdV infection, with the highest area under the curve (AUC) of 0.944 obtained for IL-10. Of note, the AUC value for the combination of IL-10, IFN-γ, and M-CSF reached 1. In conclusion, the “cytokine storm” occurred during HAdV infection in immunocompetent patients, and expression of IL-10, M-CSF, MIG, HGF, IL-1β, IFN-γ and IL-2Ra was closely associated with disease severity and could predict disease progression.

Disseminated Nocardiosis: The Complexity of the Diagnosis

Nocardiosis is a rare infection in immunocompetent patients. Nocardia spp. is an uncommon cause of prostate abscesses and is responsible for only 1-2% of brain abscess. Hematogenous dissemination can occur, and presentation of abscesses in more than two locations is required to determine a disseminated nocardiosis. The microbiological diagnosis of this agent is still a challenge due to the complexity of its identification in regular laboratories. An early diagnosis and adequate treatment with effective antibiotics are critical for treating this entity. We report a case of a patient who presented with brain abscess with a previous medical history of prostate abscess to Nocardia spp. which evolved to disseminated nocardiosis. J Med Cases. 2021;12(5):205-208 doi: https://doi.org/10.14740/jmc3673

Evaluation of Rhodotorula spp. contamination in hospital environments.

Microbiological monitoring of air and surfaces is a valuable tool for assessing the level of environmental contamination by bacteria and fungi in hospitals, especially in high-risk wards. The presence of these microorganisms requires strict control in view of their role as opportunistic pathogens. As regard yeasts, Candida albicans is one of the main opportunistic pathogens. However, in recent years, many other "non-Albicans" species have been identified that are implicated in the onset of both localised infections in immunocompetent patients and systemic infections in immunocompromised patients. The aim of the work was to evaluate the frequency of isolation of Rhodotorula spp. in environmental samples of hospital origin in order to highlight how its presence may represent an increased risk for hospitalised patients. The samples were taken in at-risk wards, divided into six types of environments, in three hospitals in southern Sardinia between 2016 and 2019. The presence of moulds and yeasts was higher in the air (55.7%) than on surfaces (44.3%) in the hospital environments (p<0.001). Similarly, the isolation frequency of Rhodotorula spp. was found to be greater (p<0.001) in the air (14.2%) than on surfaces (9.2%). This study made it possible to evaluate the presence of pathogenic fungi in hospital environments, paying particular attention to Rhodotorula spp. since it is an emerging opportunistic yeast. It also highlights the importance of control measures especially in those where immunocompromised patients are present.

Infección pulmonar y torácica por Fusobacterium nucleatum

Fusobacterium nucleatum is an anaerobic bacillus that is part of the oral microbiota and dental plaque. This can cause local and potentially remote infections, which are exceptional in pediatrics. Objective: To present the case of a patient with lung injury with chest wall invasion by Fusobacterium nucleatum. Clinical Case: An 11-year-old female immunocompetent patient who consulted due to a two-week history of cough, night sweats, without fever or weight loss, and increased volume at the left spleen thoracic level. There was no history of chest wall trauma or travel outside the country. Two weeks before the onset of symptoms, she was treated for dental caries. Imaging studies and CT scan showed left spleen pneumonia, which invades the pleura and the chest wall. A minimal thoracotomy was performed, releasing a thick, foul-smelling liquid. The studies for common germs and tuberculosis were negative. Hematology ruled out tumor lesions. The anaerobic study reported the development of Fusobacterium nucleatum. The patient was treated with penicillin followed by amoxicillin presenting good clinical and radiological responses. The dental procedure was suspected as the cause of infection. Conclusions: Fusobacterium nucleatum can occasionally cause remote or extra-oral infections in immunocompetent patients, such as pneumonia with chest wall invasion, therefore it is necessary to bear it in mind.

Granulomatous cholangitis mimicking hilar cholangiocarcinoma: a case report

BackgroundHilar biliary stricture caused by isolated fungal infections in immunocompetent patients are considered to be extremely rare and difficult to the diagnose from the outset.Case presentationWe report a unique case of granulomatous cholangitis based on isolated biliary fungal infection manifesting as obstructive jaundice and mimicking hilar cholangiocarcinoma in an immunocompetent woman. A 67-year-old Japanese woman was referred to our hospital for obstructive jaundice. She had been followed up for hypochondroplasia by the referring physician. Her total bilirubin level was 5.4 mg/dL. Viral hepatitis screening was found to be negative, and serum IgG4 was within normal limits; however, her CA19-9 level was high. Abdominal computed tomography revealed dilatation of the intrahepatic bile ducts. Abdominal echogram detected a solid mass in the hilar bile duct. Her magnetic resonance cholangiopancreatography has also revealed an abrupt stenosis of the primary biliary confluence with upstream dilatation of the intrahepatic bile ducts. Endoscopic nasobiliary drainage was then performed to improve the obstructive jaundice. Although biliary cytology did not reveal malignant findings, the bile duct in the hilum showed severe stenosis, and hilar cholangiocarcinoma could not be completely excluded. The patient had a developmental disorder based on chondrodystrophy. To avoid excessive surgical stress, such as hepatic lobectomy, we performed resection of the extrahepatic bile duct and Roux-en-Y hepaticojejunostomy reconstruction. Intraoperative frozen sections of the resection margins were determined to be negative for tumor. The resected specimen showed multiple strictures inside the common bile duct, numerous calculi in the lumen, and little free space. The final pathological diagnosis was granulomatous cholangitis due to fungal infection. The patient’s postoperative course was deemed uneventful. She was discharged from our hospital 23 days after surgery without antifungal treatment.ConclusionsFor a unique case of granulomatous cholangitis based on isolated biliary fungal infection mimicking hilar cholangiocarcinoma, we were able to avoid excessive invasion and performed appropriate surgical management.

Leclercia adecarboxylata: a rare cause of traumatic wound infections in immunocompetent patients: case reports and review of the literature

Leclercia adecarboxylata is a motile Gram-negative bacilli and a member of the Enterobacteriaceae family. It has been described as an emerging pathogen mostly isolated from immunocompromised patients. We report here, two cases of L. adecarboxylata trauma-related wound infections in two previously healthy patients and give a review of previous reports on wound infections encountered in immunocompetent patient. Both strains were sensitive to most tested antibiotics.

Fatal Case of Cerebral Aspergillum in an Immunocompetent Patient

Introduction: Cerebral aspergillum is rare and usually misdiagnosed because its presentation mimics tuberculous meningitis, brain abscess, or tumor. The diagnosis and treatment of central nervous system (CNS) infections due to Aspergillus are very difficult because accurate diagnosis is often made intra-operatively. Case Presentation: Here, we report a case of cerebral aspergilloma in an immunocompetent host. A 35-year-old man admitted with progressive left hemifacial paresthesia followed by severe pain in trigeminal nerve territory. On physical examination, except for fifth nerve palsy and difficult mastication, there was not any sensory and motor deficit. Magnetic resonance imaging (MRI) of the brain showed T1 iso and T2 low signal lesion in the left parasellar region with enhancement. The lesion is extended to the left side of the prepontine cistern in the course of trigeminal nerve, craniotomy, and total surgical resection of the mass was performed. Isolated brain lesion and the pathology from stereotactic biopsy confirmed cerebral aspergillosis. The result of testing for human immunodeficiency virus (HIV) was negative. Although the patient had two subsequent recurrences, at first, good outcome was achieved by treatment with a combination of surgical intervention, and antifungal amphotericin B deoxycholate was administered, then changed to voriconazole. Unfortunately, after two years, he experienced new progressive symptoms, and the patient died despite several reoperations due to malfunctioning of external ventricle devices as well as the treatment of recurrent post-operation meningitis and voriconazole therapy. Conclusions: Most cases of intracranial aspergillosis show that this infection is pathogenic in immunocompromised hosts; however, in some cases, invasive Aspergillus was reported as an opportunistic infection in immunocompetent patients. In these patients, though primary cranial aspergillosis is very rare, it is possible that isolated brain involvement in a previously healthy case may be explained by unknown defects in immune pathways or massive exposure to spores.

CRYPTOGENIC CRYPTOCOCCUS: A CASE OF PULMONARY CRYPTOCOCCOSIS MASQUERADING AS LUNG CANCER IN AN IMMUNOCOMPETENT PATIENT

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Cryptococcal pulmonary nodule in an immunocompetent individual is rare. Here, we perform a literature review on management of asymptomatic pulmonary cryptococcus detected incidentally on radiological imaging. CASE PRESENTATION: An 80-year-old African American male with past medical history of stage II prostate cancer and hypertension presented to our hospital with subacute onset of bilateral lower limb weakness. Extensive workup was inconclusive for etiological diagnosis but showed an incidental 1.2 x 0.9 cm spiculated left upper lobe nodular density on CT chest. Biopsy of the lesion was performed to determine cause and to rule out paraneoplastic syndrome. Cytology was negative for malignant cells but, in fact showed localized granulomatous reaction with fungal forms consistent with Cryptococcus. Serum and CSF were negative for Cryptococcal antigen. He was HIV negative and had no respiratory symptoms. Treatment with fluconazole 400 mg once a day was initiated. DISCUSSION: Cryptococcosis is a potentially life-threatening fungal infection typically caused by inhalation of spores of C. neoformans or C. gatti. Most cryptococcal infection in immunocompetent patients are detected due to radiological shadows. Rarely, they may present as spiculated lesion mimicking lung cancer, as seen in our patient.1,2 The most common radiological findings in immunocompetent pulmonary cryptococcosis are patchy consolidation and solitary nodularity1. Other radiological findings include cavitation, multinodular opacity, pleural effusion, mediastinal lymphadenopathy, and lobulated lesions. Per IDSA guidelines, asymptomatic immunocompetent patients with positive Cryptococcus lung culture may be observed carefully or treated with fluconazole 200-400 mg/day for 3-6 months3. Immunocompetent patients presenting with mild-to-moderate symptoms should be treated with fluconazole 200-400 mg/day for 6-12 months3. Alternative regimens include itraconazole and amphotericin B. Regardless of the treatment chosen, all patients should have a lumbar puncture to rule out concomitant CNS infection. Medication should be administered for about 6-12 months or until the radiological shadows disappear completely, fiberize, or calcify. Surgical intervention should be considered when the lung lesions remain stable or enlarge following 3–6 months of standard antifungal treatment or when the lesions are difficult to differentiate from tumors1. CONCLUSIONS: We decided to treat our patient with fluconazole due to evidence of reduced morbidity and mortality and prevention of progression to potential life-threatening CNS disease. However, there are possible drawbacks of therapeutic intervention including drug related toxicities and interactions, cost of drug and monthly monitoring. Thus, mutual decision making between the patient and physician is required. We plan to repeat CT chest in 3 months to reassess lung mass. Reference #1: Feng Ye, Jia-xing Xie, Qing-si Zeng et al. Retrospective analysis of 76 immunocompetent patients with primary pulmonary cryptococcosis. Lung. 2012;190:339–346. Reference #2: Kaixiong Liu, Haibo Ding, Bing Xu et al. Clinical analysis of non-AIDS patients pathologically diagnosed with pulmonary cryptococcosis. Journal of thoracic disease. 2016;8(10):2813-2821. Reference #3: Michael S. Saag, Richard J. Graybill, Robert A. Larsen et al. Practice guidelines for the management of cryptococcal disease. Clinical Infectious Diseases. 2000; 30:710-18. DISCLOSURES: No relevant relationships by Ipsa Arora, source=Web Response No relevant relationships by Kanishk Sharma, source=Web Response No relevant relationships by Sami Tahhan, source=Web Response

Parsonage-Turner syndrome associated with hepatitis E infection in immunocompetent patients

Introduction The hepatitis E virus (HEV) is the leading cause of acute hepatitis around the world. In recent years, knowledge has increased concerning extrahepatic manifestations caused by HEV, including neurological manifestations such as Parsonage-Turner syndrome (PTS). PTS is characterized by severe shoulder or arm pain and patchy paresis with muscle weakness. The aim of the present study was to assess the association between HEV and PTS. Materials and Methods We reported two cases of PTS associated with HEV, which were diagnosed in a short period of time in the same village. PTS was diagnosed by physical examination and electrophysiological studies, and serology testing for IgM, low-avidity IgG, and RNA of HEV established the diagnosis of acute HEV infection. Results A 44-year-old man who presented cervicobrachial pain accompanied by paresthesia, dyspnea, and isolated derangement of liver enzymes and 57-year-old women with cervical pain radiated to upper limbs, paresthesia, and liver cytolysis, although, this patient was initially diagnosed as having drug-induced hepatitis. Finally, the diagnosis was Parsonage- Turner syndrome associated with hepatitis e virus. In both patients, symptoms were bilateral and they required hospital admission. Both consumed vegetables are grown in a local patch and the phylogenetic analysis showed genotype 3f. Then, we reviewed the literature on PTS and HEV and we found 62 previously described cases that were more likely to be men (86.20 %) with more frequent bilateral symptoms (85.71 %). Genotype 3 is the most commonly associated. Three of those cases were diagnosed in Spain. Conclusions According to our findings, HEV should be considered in patients with neuralgic amyotrophy, including those with the absence of liver cytolysis.

Extrapulmonary Mycobacterium avium complex infections in immunocompetent patients

The Mycobacterium avium complex (MAC) includes ubiquitous bacteria that typically cause infection in immunocompromised patients. This paper reviews the presentation, diagnosis, pathogenesis, and treatment of extrapulmonary MAC infections in immunocompetent patients by compiling information from case reports identified by a PubMed search. Mycobacterium avium complex infections in immunocompetent patients can present primarily with extrapulmonary symptoms, and this makes the diagnosis of MAC infection in these patients more difficult. The American Thoracic Society has not established criteria for the diagnosis of extrapulmonary MAC infections; testing for MAC should be based on clinical suspicion or after the exclusion of all other causative agents. Methods of testing should include molecular and biochemical tests, since these tests provide more definitive identification than routine cultures. Extrapulmonary presentations usually respond well to macrolide based multi-drug regimens started as soon as a MAC infection is identified. &#x0D; Key words: Mycobacterium avium, infection, diagnosis, treatment

Invasive Phaeohyphomycosis in Immunocompetent Hosts

Phaeohyphomycosis, or invasive disease caused by melanized fungi is an uncommon infection in humans, usually in immunocompromised patients. Large case reviews reveal infections in patients without typical risk factors. We examine the data regarding these infections in immunocompetent patients. Caspase-associated recruitment domain-9 (CARD-9) mutations have been proposed as a risk factor that would predispose previously healthy individuals to develop invasive fungal disease. Several specific CARD-9 mutations have been identified with the highest burden of infection in individuals with the homozygous state. The exact mechanism by which these mutations play a role in phaeohyphomycosis is still not fully understood and will likely be an area of further investigation. CARD-9 mutations and/or deficiency in humans is associated with invasive and disseminated infections due to melanized fungi. Further studies to examine the implications for prevention and management of these infections are needed.

Hemophilus influenzae and Parainfluenza Virus Pneumonia in a Patient with AIDS

Patient: Male, 64-year-oldFinal Diagnosis: Hemophilus influenzae and parainfluenza virus pneumonia in a patient with AIDSSymptoms: Shortness of breathMedication:—Clinical Procedure: Bronchoalveolar lavageSpecialty: Infectious DiseasesObjective:Rare diseaseBackground:Parainfluenza viruses (PIV) are known to cause mild respiratory tract infections in immunocompetent patients but can cause severe infections in immune-compromised patients such as transplant recipients and children with HIV. PIV infection in HIV-infected adults has rarely been reported. We report a case of PIV pneumonia in an adult with AIDS who was successfully treated with oral ribavirin.Case Report:A 64-year-old man with history of acquired immune deficiency syndrome (AIDS) was admitted to the hospital with shortness of breath that began 3 days before. He was in respiratory distress and required mechanical ventilation on arrival. A bronchoalveolar lavage (BAL) culture was positive for Hemophilus influenzae and a respiratory viral panel was positive for Parainfluenza virus. The patient was initially started on Cefepime and Trimethoprim- Sulfamethoxazole and later changed to Ceftriaxone based on culture results. As the patient’s condition did not improve after 48 h, oral ribavirin was added to treat PIV. The patient subsequently improved and was extubated after 72 h.Conclusions:Oral ribavirin can have a beneficial effect in AIDS patients who have PIV-associated pneumonia. Further investigation of the benefit of oral ribavirin in similar cases is warranted.

Patient characteristics, clinical manifestations, prognosis, and factors associated with gastrointestinal cytomegalovirus infection in immunocompetent patients

BackgroundGastrointestinal (GI) cytomegaloviral (CMV) infection is common among patients with immunocompromised status; however, data specific to GI-CMV infection in immunocompetent patients are comparatively limited.MethodsThis retrospective study included patients diagnosed with GI-CMV infection at Siriraj Hospital (Bangkok, Thailand) during 2008–2017. Baseline characteristics, presentations, comorbid conditions, endoscopic findings, treatments, and outcomes were compared between immunocompetent and immunocompromised.ResultsOne hundred and seventy-three patients (56 immunocompetent, 117 immunocompromised) were included. Immunocompetent patients were significantly older than immunocompromised patients (73 vs. 48.6 years, p < 0.0001). Significantly more immunocompetent patients were in the ICU at the time of diagnosis (21.0% vs. 8.6%, p = 0.024). GI bleeding was the leading presentation in immunocompetent, while diarrhea and abdominal pain were more common in immunocompromised. Blood CMV viral load was negative in significantly more immunocompetent than immunocompromised (40.7% vs. 12.9%, p = 0.002). Ganciclovir was the main treatment in both groups. Significantly more immunocompetent than immunocompromised did not receive any specific therapy (25.5% vs. 4.4%, p ≤ 0.01). Six-month mortality was significantly higher among immunocompetent patients (39.0% vs. 22.0%, p = 0.047). Independent predictors of death were old age and inpatient or ICU clinical setting. Treatment with antiviral agents was the only independent protective factor.ConclusionGI-CMV infection was frequently observed among immunocompetent elderly patients with comorbidities or severe concomitant illnesses. GI bleeding was the most common presentation. Blood CMV viral load was not diagnostically helpful. Significantly higher mortality was observed in immunocompetent than in immunocompromised patients, but this could be due to more severe concomitant illnesses in the immunocompetent group.

Isolation of Staphylococcus xylosus from Urinary Tract Infection in Al-Diwaniya City, Iraq

One hundred diuresis samples were collected from patients with urinary tract infection from Al-Diwaniyah General Teaching Hospital in Al-Diwaniyah city for the period from January 1, 2019, to August 1, 2019, as 35 isolates belonging to the sex of streptococcus were isolated and with an isolation rate of 35% of the total 100 diuresis samples, The yield of 20 isolates to the negative staphylococcus aureus was tested for cocaine, and 5 isolates were of type S. xylosus, with an isolation rate of 25% of the total negative staphylococci for testing cocaine, and by 5% of the total of the reagent samples. These biochemical bacteria were diagnosed using the API Staph system. The clinical stages of the infection are in the subacute or chronic phase without clear symptoms. Streptococcus unproductive streptococcus resistant and anti-life antibody novobiocin, especially S. saprophyticus, are most common in urinary tract infections in immunocompetent patients, and mild infection in women is accompanied by dysuria. Young women between the ages of 16-16 years old to 42%. It affects the ureter in men. It can cause cystitis, pyelonephritis and glomerulonephritis. This group possesses a high affinity to epithelial cells, and this comes from the participation of different proteins such as a 160-Kd protein with Hemagglutinin and Fibriller protein, and it is symbolized by 95-Kd, which is found in 98% of clinical isolates.

Characteristics of nocardiosis patients with different immune status from a Chinese tertiary general hospital during 8-year period: A STROBE-compliment observational study.

Nocardia is an opportunistic pathogen from environment, which is generally thought to infect immunosuppressed patients (ISPs), but recent studies showed it could also cause infections in immunocompetent patients (ICPs).The aim of this study was to compare the clinical characteristics, patients’ outcome, Nocardia species’ identification, and antibiotic susceptibility profiles of nocardiosis between ICPs and ISPs.The detailed clinical data were collected from all the nonrepetitive nocardiosis patients during 2011 and 2018, from a tertiary general hospital in Beijing, China. Then each Nocardia isolate was identified to species level by DNA sequencing. The antibiotic susceptibility testing was performed by E test method, and interpreted following CLSI M24 document. The clinical and microbiological characteristics between ICPs and ISPs were compared statistically.A total of 23 nonrepetitive nocardiosis patients with detailed clinical data were enrolled in this study. Among them, 9 were ICPs and 14 were ISPs. All the skin and soft tissue infections occurred in ICPs (33.3% vs 0%, P < .05). Bronchiectasis occurred more frequently in ICPs (44.4% vs 21.4%), whereas chronic kidney diseases and coinfection with aspergillosis occurred more frequently in ISPs (35.7% vs 0%, 35.7% vs 0%, respectively), although they did not reach the statistical significance. There were no significant differences in other clinical characteristics, Nocardia species’ identification, and antibiotic susceptibility between ISPs and ICPs (P > .05).Nocardiosis could occur in both ISPs and ICPs. Skin and soft tissue infection and bronchiectasis occurred more frequently in ICPs. Chronic kidney diseases and co-infection with aspergillosis occurred more frequently in ISPs. These characteristics should be noticed by physicians in diagnosis of nocardiosis.

Pneumocystis Pneumonia: Still a serious disease in children.

Pneumocystis carinii pneumonia is a common opportunistic respiratory infection among children with human immunodeficiency virus and a weakened immune system. The primary infection in immunocompetent patients may be asymptomatic, whereas fever, shortness of breath, night sweats, nonproductive (dry) cough, pneumonia, progressive respiratory distress and apnea are cardinal symptoms of full-blown pneumocystis pneumonia. The diagnosis can be confirmed by histochemical staining of biological specimens or, recently, by polymerase chain reaction. International recommendations indicate that the drug of choice is the intravenously administered trimethoprim-sulfamethoxazole combination. Early diagnosis and appropriate treatment reduce the mortality of the disease. This article briefly highlights the epidemiology of Pneumocystis pneumonia, its diagnosis and therapeutic options in the pediatric population.

Human Herpesvirus-6 may be Neurologically Injurious in Some Immunocompetent Children.

Human herpesvirus 6 (HHV-6) can infect the central nervous system in immunocompromised individuals. Less is known, however, about HHV-6 infection in immunocompetent patients. This study evaluated the neurologic features and prognosis of HHV-6 infection in immunocompetent patients. The medical records of patients aged 1 month to 18 years who underwent cerebrospinal fluid examinations and were tested for 6 viruses, including HHV-6, by multiplex polymerase chain reaction were evaluated retrospectively. During the study period, 252 children were included. None had underlying disease and all were immunocompetent. Their mean age at diagnosis was 40.98 ± 47.65 months. Of these 252 patients, 144 (57.1%) were diagnosed with meningitis, 84 (33.3%) with febrile seizure not induced by meningitis, and 24 (9.5%) with encephalitis. Of the 9 patients positive for HHV-6, 3 (33.3%) had encephalitis, 3 (33.3%) had meningitis, 1 (11.1%) had complex febrile seizure, and the other 2 patients had fever alone. Outcomes were worse in the seizure group (Fisher exact test, P = .048), especially in patients with status epilepticus (Fisher exact test, P = .012), than in the other groups. Encephalitis patients with and without HHV-6 differed significantly in age (24.0 ± 10.8 vs 63.4 ± 47.7 months, t-test P < .05), with status epilepticus being more frequent in those with HHV-6 (Fisher exact test, P = .010). All 3 encephalitis patients positive for HHV-6 had neurologic sequelae; 2 who had mild sequelae were treated with antiviral agents and intravenous immunoglobulin. HHV-6 may not be completely benign in immunocompetent children. It can be associated with encephalitis and poor prognosis.

2307 Liver Abscess Complicated by Invasive Klebsiella Syndrome Resulting in Endophthalmitis

INTRODUCTION: Invasive Klebsiella pneumoniae Syndrome is characterized by liver abscesses, bacteremia, and metastatic infection – particularly endogenous endophthalmitis. First described in Southeast Asia in the 1980s, this syndrome has been increasingly identified in North America and is linked to virulent strains defined by hypermucoviscosity specific capsular serotypes, especially serotype K1 and K2. Following the development of a liver abscess, bile leak is a potential complication that may benefit from endoscopic management. CASE DESCRIPTION/METHODS: A 68-year-old female presented with 5 days of fevers, rigors, &amp; chills. Blood cultures grew mucoid Klebsiella pneumonia, and a large hepatic abscess was noted on abdominal imaging. Shortly after admission, she developed left-sided visual deficits, with floaters and decreased visual acuity. She was found to have endogenous endophthalmitis and received intravitreal antibiotics. A percutaneous hepatic drain was placed, and she was treated with IV ceftriaxone. At a one-week follow-up, she reported decreased drain output and right flank pain. The drain had bilious output and was concerning for bile leak. ERCP showed a contrast leak at the level of the common bile duct, and a stent was placed. Repeat cultures were sterile, with no output following stent placement, so the drain was removed. She completed 6 weeks of antibiotics, and follow up imaging demonstrated marked improvement. She underwent vitrectomy with anterior chamber washout. Despite the resolution of abscess and bacteremia, she had no recovery of vision in the affected eye. Although the Klebsiella strain was of mucoid nature, the traditional K1 hypermucoviscosity serotype was negative. Only K1 serotype was tested for in our patient. DISCUSSION: Klebsiella pneumoniae is known to result in highly invasive community-acquired infection in immunocompetent patients without underlying hepatobiliary or intestinal disease, particularly the K1 and K2 subtypes, which are the most virulent of the known serotypes. Their capsules essentially protect the bacteria from phagocytosis. Endophthalmitis is a common complication, with high morbidity. Liver abscesses are treated with antibiotics and percutaneous drainage. Development of bilious drain output may signal the development of a bile leak, which can be successfully managed with endoscopic stenting.

1738 Refractory Candida Esophagitis in an Immunocompetent Patient: A Rare Presentation

INTRODUCTION: Candida esophagitis is an invasive fungal infection of the esophagus classically caused by Candida albicans. It is usually considered an opportunistic fungal infection affecting those who are immunocompromised. Recently however, there has been an increased incidence of the infection in immunocompetent patients. Here present a case of refractory candida esophagitis in an immunocompetent female. CASE DESCRIPTION/METHODS: The patient is an 83-year-old immunocompetent female with a past medical history of congestive heart failure, hypertension, hyperlipidemia, diabetes mellitus, venous insufficiency, obstructive sleep apnea, fibromyalgia, and degenerative joint who presented to the clinic with a 5-month history of dysphagia and odynophagia. She was recently diagnosed with candida esophagitis through esophagogastroduodenoscopy (EGD) and biopsy and was treated with fluconazole with temporary resolution of symptoms. We performed a repeat EGD which showed diffuse whitish mucosal patches consistent with severe candida esophagitis of the entire esophagus (Figure 1). Biopsies stained with GMS special stain confirmed the diagnosis. Due to the patient’s previous resistance to fluconazole, the patient was referred to an infectious disease specialist who placed the patient on a Nystatin swish and swallow for 14 days with a subsequent course of fluconazole. One-month post-treatment, a follow-up EGD was performed and showed significant improvement with few scattered specks of whitish mucosal exudates in the entire esophagus consistent with mild candidiasis (Figure 2). One month later at follow-up, the patient reported complete resolution of symptoms. DISCUSSION: Candida esophagitis was thought to be a disease of the immunocompromised (i.e. AIDS patients) but, has shown to be on the rise in immunocompetent patients. Several studies showed that diabetes, old age, corticosteroid use, and antibiotic therapy are all major risk factors for development of the infection in this population. It is usually an easily treatable condition through the use of fluconazole, an antifungal agent that is usually seen with great success. However, there have been reports of resistance to the drug and a possible explanation of this is its widespread use leading to growth of fluconazole-resistant strains such as non-albicans candida strains. Species identification and fluconazole susceptibility testing may aid in adjustment of treatment protocols for those with recurrence of candida esophagitis.

2538 Severe Protein-Losing Enteropathy and CMV Duodenitis in an Immunocompetent Male

INTRODUCTION: Cytomegalovirus (CMV) infection, typically associated with immunodeficiency, has been reported to also occur in immunocompetent patients. CMV infection of the gastrointestinal (GI) tract is uncommon in immunocompetent hosts and typically involves the lower GI tract. We encountered a case of CMV duodenitis associated with severe protein-losing enteropathy in an otherwise healthy male. CASE DESCRIPTION/METHODS: A 27-year-old man with a 2-year history of mild, intermittent non-bloody diarrhea presented with 2 weeks of worsening diarrhea, epigastric pain, nausea, vomiting and poor oral tolerance. His only medication was emtricitabine/tenofovir for HIV pre-exposure prophylaxis, initiated 4 months prior to presentation. Physical examination revealed a tender epigastrium and anasarca. Laboratory evaluation showed WBC 13.2 K/mcL (12.2% monocytes), albumin 1.9 g/dL, AST 64 U/L, ALT 77 U/L, total bilirubin 1.0 mg/dL, INR 1.0, and lipase 346 U/L. Serum HIV antigen/antibody was negative, and CD4 cell count was 873 cells/mcL. Urinalysis was unremarkable and was without proteinuria. Stool studies were negative for common enteric bacterial pathogens, Clostridium difficile, Giardia, and ova/parasites. Fecal calprotectin was elevated at 390 µg/g. MRI/MRCP imaging of the abdomen and pelvis showed a thickened duodenum, and peripancreatic fat stranding and fluid (suggestive of acute pancreatitis), without biliary or pancreatic duct dilation. EGD showed severe duodenitis with diffuse erythema, mucosal denudation, patchy erosions, and nonbleeding ulcerations. Biopsy with immunostain revealed CMV duodenitis. Serum CMV DNA was mildly elevated at 142 IU/mL. Following multidisciplinary discussion, supportive care was provided without antiviral therapy. Over the next month, the patient improved clinically, with normalization of serum albumin, transaminases, and CMV titer. DISCUSSION: Several reports have described tissue invasive CMV infection in immunocompetent patients, primarily involving the colon. CMV duodenitis and pancreatitis are rare, even in immunocompromised patients. Our case describes a healthy man with severe CMV duodenitis resulting in protein-losing enteropathy. CMV likely caused mild acute pancreatitis in our patient as well. A recent systematic review did not support antiviral therapy for immunocompetent patients with CMV. Supportive care with close monitoring may be sufficient; however, further investigation is needed to routinely support this practice.